Introduction

Although arts-based methods in research have been utilized in many disciplines including creative arts therapies, anthropology, sociology, and psychology, their use in health research is more recent [1, 2]. The form of these methods is varied and comprise the visual arts (e.g. drawings, photographs, collage), the performance arts (e.g. drama, film, dance, music) and literary arts (e.g. poetry, storytelling) [3]. Some approaches have been employed in health research across sub-Saharan Africa, particularly in the field of HIV prevention and intervention and primarily using theatre and music [2]. There is burgeoning evidence of the effectiveness of their use in South African health research [4, 5]. Gittings and colleagues (2022) highlight their value in reflecting on and engaging with sensitive topics such as HIV with an adolescent community advisory group over a twelve year period [4], and Honikman and colleagues (2020) support their effectiveness in facilitating dialogue with nurses in primary healthcare settings in an attempt to integrate mental health services more compassionately with patients [5]; but less is known about their utility in violence-related research in a low-resource setting like South Africa. We were interested in exploring their use in preparation for a large, longitudinal cohort study investigating multigenerational transmission of violence in South Africa [6].

Interpersonal violence is pervasive in South Africa and is the second leading cause of loss of disability-adjusted life years [7]. Intimate partner violence is reported by 32% of women in population-based studies [8] and rates of femicide are six times the global average [7]. Violence against children and adolescents is equally rife with national estimates of sexual abuse against girls at 15% and boys at 10% [9]. Given these rates of violence, it is prudent to explore experiences of those exposed to better understand the mechanisms of violence and its transmission across generations [6].

Research that employs non-verbal methods, such as drawing or image making, may offer a principally ethical means of engaging participants in the process of research as these can be more developmentally attuned to the needs of participants, bypassing language and involving participants in dynamic and embodied ways [10]. They may minimise stress inherent in the power dynamic between participants and those who interview them; and through this, voices of participants may be more pronounced and valid, enabling communication [11, 12]. They may also offer a platform that is more easily engaged with where literacy levels may be low, as is the case in South Africa. In the most recent Progress in International Reading Literacy Study (PIRLS), 81% of Grade 4 children (10 year olds) are unable to read for meaning, a statistic that hasn’t changed much in the last decade [13].

Concerns that adult data-gathering techniques, that are predominantly grounded in language, may block or distort the perspectives of children have led researchers to seek creative methods to effectively engage children and adolescents in the research process [14]. On account of their participatory nature, arts-based methods are argued to more actively involve children and prevent tokenistic participation [15]. The Convention of the Rights of the Child [16] endorses children’s participation and these methods may ensure children’s voices are more thoroughly and authentically engaged with and their rights more ethically expressed and facilitated. “Enjoyment, empowerment, and emancipation” are intrinsic to participation and these methods are facilitative of these principles [17]. In addition, a recent qualitative systematic review shows that using arts-based methods in sensitive research with children and adolescents “1) recognize and makes visible previously invisible experiences, acts, voices and histories; 2) nurture change and transformation in the lives of the youth; and 3) allow exploring the more-than-human, more-than-present and less-than-conscious aspects in the lives of youth and children–aspects that traditional study methods might not readily access” [18]. Violence experience can be an ‘invisible experience’ that is ‘less-than-conscious’ and research on violence may benefit specifically from arts-based methods such as drawing, for both child and adult populations.

Another key aspect of studying violence is the compromised mental health that is implicated in trauma exposure of participants. There is evidence that creating imagery in an interpersonal space characterised by kindness, active listening, and empathy has potential to improve mental health [19]. Researchers applying visual and narrative methodologies should be particularly sensitive to the affective impacts of their work, as artistic creation and witnessing can be experienced as an emotive process [20]. The use of image and symbol can support communication for those who struggle to put experience into words, but also for those who are not capable of articulating traumatic exposure [21]. Drawing facilitates verbal reports of ‘emotionally loaded’ events [22] and resultantly, is a useful tool to assess and elaborate traumatic experiences [23], making drawing especially appropriate as a method in violence research. This may be particularly relevant in South Africa, where trauma exposure in the general population is high [24]. However, importantly, in this process of defamiliarization participants, and indeed interviewers, may be confronted with elements of their lives that they manage to defend from consciousness in their everyday existence [25].

Interviewers thus need capacity to safely manage emotions if they emerge in the process of data collection and the ability to facilitate use of the material, particularly with those who may not be used to the freedoms of utilising them. Especially in low-resource settings, children, adolescents and adults may not have been exposed to more than paper and pencils in their schooling or outside of it. The South African education system has been described as ‘essentially dysfunctional’ where resources are scarce in the public sector [26]. Importantly, the mental health of interviewers engaged in qualitative research must be recognized as it is both emotionally and interpersonally demanding [27] and may be even more so using arts-based methods. It requires the interviewer to be personally present, open, able to safely manage emotions and probe meaningfully and sensitively. Particularly in violence research, where interviewers are intentionally asking about stigmatizing and sensitive information, often with highly vulnerable participants, training and support needs to be managed and budgeted for appropriately.

Arts-based methods often yield a variety of data, including visual data such as photographs, film, images and drawings that implicate visual ethics, i.e. how to manage data that could identify individuals through its visual nature. The ethical guidelines available for researchers do not always provide sufficient reference to the creation and use of imagery and to the key issues of informed consent, confidentiality and ownership [28]. For those who experience violence, issues of safety and control may be salient and need additional consideration in terms of interaction and what is produced. Ensuring participants feel safe and have a sense of control of the process becomes crucial. This applies to the image created, the interaction around the image with the interviewer, but also relates to space (where and how the image is being made?), materials (are participants familiar with and comfortable using these?) and storage (where are the images kept and can participants take their image with them after the interview if it might bring inadvertent harm to those that live in violent circumstances?).

Notwithstanding these challenges, visual methods, particularly drawing, can be easily utilized in resource-constrained research contexts as there is a simplicity to them; one needs few materials to complete tasks. Drawings are concrete and tangible, inexpensive and easily replicated, and the visual prompt of drawing can lead to storytelling with ease [29]. Drawings often foster personal reflection and insight; the image reveals to the artist something about the experience that might not have been processed and in completing an image and processing it verbally, when one describes the image to another, new information might come to light. This opportunity for reflexivity may be helpful for participants. Also, the methods can help participants articulate and share events that they may not have talked about before or that are difficult to talk about. Children asked to remember an event through drawing and telling versus telling alone remembered twice more significant detail [22]. Similarly, in a study with older adult eyewitnesses and victims of crime, those who drew a sketch of the event were able to recall significantly more accurate information than those who did not [30].

Drawings have a history of being used in projective testing and assessment as they are seen to reveal underlying psychic information about the artist [31]. As art making is a cognitive behavioural task, it is reasonable to assume that the artwork may divulge something about the artists’ thinking and feeling [32]. Projection is commonly regarded as the tendency to externalise aspects of the self and drawings are considered to serve as ‘projective containers’ [33]. For the purposes of our research, drawings were not used for diagnostic outcomes or assessment, but rather as a platform for personal storytelling.

Due to the existing gaps in the research on the acceptability and feasibility of art-based methods specifically within the South African context and with victims and/or perpetrators of interpersonal violence, a pilot study was conducted. The purpose of the pilot study was firstly, to prepare for a longitudinal multigenerational cohort study on mechanisms that underly the intergenerational transmission of violence, and secondly, to observe the potential of using four arts-based research methods. This study reports on the experiences of interviewers and participants regarding the feasibility and acceptability of using these methods in violence research with adults and children.

Materials and methods

Results

Discussion

Our pilot study found that using arts and play-based methods in multigenerational violence research is feasible and acceptable to participants and interviewers. These methods worked well for nearly all participants regardless of age or ability. They can enhance what researchers (and participants) can discover through their capacity to facilitate disclosure, particularly around stigmatizing and sensitive experiences like violence [21]. Perhaps this is due to the increased safety these methods provide in their ability to facilitate expression and allow participants personal distance from the content of violence they are sharing with interviewers [21].

Creative arts therapies are known to support mental and physical wellness, improving the ability to communicate experience, express feelings and feel safe [60], which may position these practices well for their inclusion in equitable research, especially for those who may experience conventional methods as ‘unsafe’ or constrictive. Creative arts therapies have been proven effective for many mental health problems, but especially for treatment of trauma and complex PTSD [19, 61, 62]; a potential outcome of violence exposure. These methods enhance memory recall, enabling memories to be processed and for the ‘artist’ to have control over this process [63], an important aspect to consider in violence research where participants may have experienced significant lack of control. The creative product may function as a container for affect, promoting emotional regulation [64]. Words and meaning can be ascribed to memories manifest in tangible form for participants through the product; they can be arranged and consolidated to produce coherent narratives and eventually to integrate experience [65]. Importantly, this can also encourage violence being named as such, validating the feelings or thoughts associated with this exposure [66, 67]. Being listened to when communicating personal history to another (i.e. participants talking about themselves through their drawings without interviewer interpretation) can reduce the isolation many feel as a result of experiences marked by stigma, improving self-worth and agency which have knock on positive effects for mental health [68].

Interestingly, a bulk of creative arts therapy research with patients who have experienced trauma is supported with neuroscientific findings that recognize the importance of arts-based strategies that do not rely solely on language for processing [69–71]. The neuroscience behind imagination has shown that when people visualise something and remember it, the activity shown in their brain resembles that associated with the real experience [72], suggesting that our imagination has a real and tangible impact upon how we feel. This means that imagined phenomena are not just a ‘figment of our imagination’; they are part of our embodied experience and to manage them we may need our body’s investment in processing; something art and play-based approaches facilitate in clinical practice, but perhaps in research too.

Engagement in art and play-based methods may hold therapeutic value for research participants. The mechanisms that underlie mental health change in the creative arts therapies are understudied but emerging evidence highlights embodiment (physicality of the arts, body awareness, engaging mind-body connection), concretization (the image or product facilitate verbal reflection and self-knowledge), symbolism and metaphor (unconscious processing and externalization, self-expression), enhanced self-efficacy and motivation [60]. Similarly, the mechanisms for change in play therapy include facilitating communication (self-expression, teaching), fostering emotional wellness (counterconditioning fears, stress inoculation, catharsis), enhancing social relationships (attachment, social competence, empathy), and increasing personal strengths (creative problem-solving, resiliency, self-regulation, self-esteem) [37, 73]. There is possibility that these positive effects could be experienced through participation in research as well. Through the process of artmaking, play, and joint attention, participants may increase their ability to become more self-reflexive and self-aware about the issues being investigated. Through reflection one is better able to gain a perspective and when this is shared within a confidential, supportive and attentive interpersonal interaction, in some instances, the action has transformative potential. This is particularly the case with stories that may not have been told or heard before, which is often the case in violence research. Our study supports other local research with vulnerable violence exposed participants and their perceived benefit of inclusion, having an opportunity to share adverse experiences with others in a ‘safe space’ [74].

It is possible that the most at-risk participants had more difficulty focusing and concentrating, regardless of age. Research demonstrates that children in South Africa are significantly exposed to violence during childhood which places them at risk for trauma [75]. Often traumatized children may present with symptoms of attention deficit disorder (ADHD) that is more likely to be complex PTSD related or that these two phenomena are highly interrelated [76]. Dysregulated affect, hyperactivity, and irritability are difficult symptoms to manage in a research interview and may require additional expertise and resources. It also has implications for any violence-related interviewing of children and adolescents in the South African context, or anywhere that violence against children and youth is highly prevalent.

We found that children as young as 4 years old could participate in our pilot study [34]. With very young children, researchers have highlighted that verifying the information they provide may be difficult, and that data elicited may not be a genuine reflection of the way they understand the world [77]. Drawing has been advocated as a possible pathway to true representation of children’s thoughts and may elicit communication in a way that best exemplifies the way they see the world [78]. A marked strength of drawing is its direct and immediate aptitude to reflect back to its maker the thoughts derived through its making. Perhaps this explains young children’s seemingly natural interest and gravitation towards drawing. It is instantaneously all-inclusive and interactive in a manner that writing and speaking are not. Children’s felt sense of understanding of their contexts might easily be given expression in drawings. But, for children to be afforded the opportunity to engage in the complexity of their drawings and the time required for such, there needs to be emphasis of these necessities in the training and research provided. Drawing in our study led to improved mutual understanding between child participant and adult interviewer. Disclosure also led to increased referrals for some vulnerable children, another reality to be managed purposively. Although no child participants showed obvious levels of distress by talking about violence or drawing pictures, the circumstances in which children lived and the experiences they had were distressing. Interviewers were trained to manage disclosures appropriately and provide empathic support to participants, whether children or adults, through processes of mandated reporting. Having a full time social worker on the project who intervened in these cases and ensured they were effectively managed was a source of support to participants as well as interviewers. This is particularly important in contexts where child protection and social services may be ineffective or unobtainable.

In drawing or creating any arts-based product, there is an image or artwork that is produced. Used in research, this creates a triangular relationship between participant, interviewer and image. The participant and the interviewer join their gaze and attention towards the image which gives voice to the process and experience of the participant. Instead of looking at the participant, the interviewer looks with, facilitating a more comfortable dialogue and storytelling perspective. This is significant in cultures where making direct eye contact as children with adults might be perceived as disrespectful or disobedient [79]. The image may bridge these cultural influences and may create safety in directing shared gaze towards the third entity in the triangle. The idea of ‘joint gaze’ is one grounded in developmental psychology and art therapy where a participant and adult join together in joining their gaze and by extension, their attention [80]. The capacity for joint attention cannot be taken for granted and is a skill that needs mentorship and development in interviewers. It is also a skill more challenging to utilize with those who may have attachment difficulties [81, 82], and the intimate partner violence environment tends to put caregivers and their children at risk for perpetuating insecure attachment relationships [83]. The implication is that the participant requires the underlying cognitive and emotional skills [84] of joint attention to be able to look, think and reflect on their own position and the position of their image during the interview. Thinking about what the image may reflect or mirror back [85] may need to be facilitated and supported by the interviewer within the triangular relationship and may be too sophisticated a skill to master in some circumstances.

Interviewers seeking this data need adequate practice with consistent training regarding the power and potential of sharing imagery interpersonally around violence. Values clarification is important in training, both regarding violence, the use of imagination, and art and play as methods of data collection. Reflexivity is a vital ethical issue to consider in using non-verbal approaches and should be consistently engaged with. The visual image is a commanding medium of communication, but visual ethics need intentional guidance and oversight. Participants must consent to their image being used in research and more broadly being shared with others outside of the research interview. Interviewers should ensure that no identifying information is held within an image that can reveal the identity of the participant, but also their family members. This raises tensions between revealing and concealing the contents of visual images and who has ‘the right’ to claim ownership of images and show them to others [25].

The visual images that researcher’s study and engage with form part of a wider narrative that directs their framing, and when we ask participants to create something visual, our understanding of these images is often grounded not just on the image itself but the consequent elicitation interview. The interviewer should be encouraging of creativity and respectful of what it yields for it to be effective. Images themselves are also open to interpretation and reinterpretation, both from those who create them, but also those who get to look at them and as Hall maintains, images rarely contain a singular or ‘true meaning’ [86] but invite dialogue and meaning making opportunities. Interviewers must be alert to their own bias in interpreting images without getting proper feedback from participants on what they themselves attribute to their imagery and storytelling about them. In addition, power and positionality, both between participant and interviewer, but also between interviewer and image, need a frame that is tolerant and without judgement; one that is imbued with interest and curiosity. This is difficult to achieve without practice. It is helpful for interviewers to be informed about participant developmental capabilities in drawing and play, i.e., being privy to the drawing abilities of children and adults across development [87], recognising that there may be delays in these abilities and just because a child can’t ‘draw like a 5 year old’ doesn’t mean that their image can’t tell their story. Lastly, the costs of the emotional involvement (of both participant and interviewer) in reliving their negative experiences during interviews and through drawing needs to be dealt with in research [88]. The investigative team and line managers were available and encouraged interviewers to discuss interactions that were challenging or triggering for interviewers, purposively creating a research culture sensitive to vicarious trauma possibilities and being responsive to it.

In our review of the literature, we could not find studies from South Africa that investigated the use of arts-based methods utilized by fieldworkers/interviewers conducting violence research, i.e. not utilized as an intervention per se and not applied by specialist therapists. This indicates an opportunity to explore in future research to assess the utility of these methods in cross sectional studies on violence.

Conclusion

Our pilot study revealed that arts-based methods can lead to rich data around violence experience in children and adults alike and can be successfully implemented in a low resource setting in rural South Africa. These methods, used in violence research, may offer participants benefits through active engagement, joint attention, memory recall, personal expression and integration of narratives. It may also be beneficial to have an opportunity to disclose personal adversity through these means. Interviewers require increased capacity and sensitivity in using the methods carefully, to maximize their full potential, and ongoing mentorship is indicated. These approaches are underutilized in health research and may offer improved means of understanding violence whilst ethically engaging participants.

Supporting information

Acknowledgments

We would like to acknowledge our participants and dedicated interviewers.